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ethics of counseling and therapy

The fantasy of having a closer relationship with one’s therapist occupies the mental space devoted to imaginary things. It must, because few counselors permit such a connection. Professional ethics generally prohibit the dual role of therapist/friend and therapist/lover. Yet, there is value in fleshing-out what this double-bond would look like in practice.

Responses to my recent post, Being Excluded From Your Therapist’s Life, suggest the fantasy dies hard. What follows is an effort to describe how the relationship would function if brought to life — the day-to-day lives of a shrink and his patient. I invite you, dear reader, to think along with me. Let me know if my concerns are off-base. Even more, once you finish reviewing my ideas, I’d love to read your own notion of how to create the connection some of you want with your therapist: an outline better than the current prohibitive model you say is frustrating.

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I will use myself as an example. First, were I to lower therapeutic barriers, I’d accept only unsolicited volunteers for friendship. No direct invitation would be addressed to patients. I’d then need to consider who I’d enjoy having as a friend from among those who expressed an interest. Let’s assume three people both want this and seem a good fit for me. Any number I might choose would be arbitrary. Pick a different one if you like. Remember, however, the bigger the numeral, the harder it will be for this system to work.

FIRST PROBLEM: Even without an announcement, I assume some folks would become aware of my possible willingness to pass time with them informally. This might happen by word of mouth, within a written statement of clinic policies given to patients beginning treatment, or due to a general change in the ethical guidelines applying to all clinical psychologists.

A therapist is human. He finds some people more compatible than others. This doesn’t mean the potential chums are better than anyone else, only that they possess the kind of personal qualities the doctor enjoys socially. Unfortunately, “no” would be the message delivered to some people. Imagine how those “blackballed” might be affected, including the negative impact on the therapeutic alliance. In effect, my partial openness to friendship necessarily establishes a three-tiered clientele:

a. Those clients who do not request friendship.
b. Patients who become friends.
c. The unfortunates who get rejected.

Might some occupants of the lowest tier infer I offer them professional services only to make a buck, since I don’t want to socialize? While not true, any alternative explanation sounds hollow, at least to me.

SECOND PROBLEM: How might I differentiate between time spent as a therapist and hours passed as a pal? That is, what if a client with me at Starbucks begins to talk about personal problems? How should I respond? I’d need to choose among three roles:

a. A sympathetic friend.
b. A therapist doing an unscheduled session out of the office.
c. A doctor who thought he was off-duty.

If I react as the doctor I must then remind my coffee-partner I am not at work. Indeed, I might emphasize that we are having a non-therapeutic relationship at his request. What do I do, however, if my friend ignores the boundary or gets emotionally overwhelmed in the restaurant? In addition, how do I deal with the question of a fee for my service if I find myself doing lots of therapy outside the office?

THIRD PROBLEM: I am the proud owner of a good social life, as complete as I’d like it to be. In our example, it has suddenly been enlarged by three people. My downtime instantly becomes “jammed-up.” My freedom to enjoy family and personal connections already present, many of long-standing, is now reduced. Disappointments among both chums and loved ones are inevitable. This will be predictably stressful. How do I choose which relationships to honor? Would arguments or resentments follow? Would some of my patient/friends experience surprise or worse when their expected access to me is less than they dreamed? Might this add to the history of rejection that triggered at least a few of them to enter counseling in the first place?

FOURTH PROBLEM: As noted in “Problem Three,” the abrogation of my former ethical restrictions leaves me trying to find time to do what I want, including contact with children, spouse, old buddies and recent dual role chums. Perhaps you’d advise me to limit new patient/friends from the start by saying to volunteers, “Yes, I’m open to being your friend, but I can’t because I just don’t have the time.” I doubt this would satisfy them forever and might seem phony.

Remember, too, I am introverted by nature. Were I to add the three newbies and try to keep the rest of my social network unchanged, I imagine draining myself. Might I become resentful about this? If so, would anger and fatigue intrude on all my relationships, as well as diminishing my competence as a psychologist? The answer would be “yes” to both questions.

FIFTH PROBLEM: Let’s assume the new ethical guidelines still prohibit sex, broadly defined. In other words, kissing, fondling, and everything more. Further imagine I have a fulfilling marriage (which I do). Now, however, I am spending time as the “friend” of a woman (or women) I find attractive. Age is not important, type is not important, whether you’d be attracted to them is not important. The only consideration of consequence is my susceptibility to the allure of such a person or persons. Yes, perhaps I could screen out those whose magnetism I felt from the start, but this wouldn’t prevent attraction from developing in the course of the friendship. Nor do I assume that both of us would experience the same beguilement, but I’m expecting sometimes we would.

You all know nothing stops two people who begin a relationship (casual, professional, or otherwise) from becoming sexually intimate down the line. All of us are the offspring of ancestors who had intercourse. Lots of it. We are built to reproduce. Oscar Wilde put it best, “I can resist anything except temptation.” Under my new rules, however, I’d have to do just that. Had I maintained the previous metaphorical moat between myself and my patients, those ethical principles would have helped in cementing this boundary. Avoiding temptation is far easier than resisting it. Our hypothetical scenario puts me pretty much on my own, doing enjoyable activities — as one does with platonic companions — a few of whom happen to be “hot.” The slope is slippery and my skis are on. If I begin this downward adventure I will destroy my patient, my family, and myself.

SIXTH PROBLEM: The decision to permit friendships with clients rests on an implicit assumption: I have something to offer as a friend no one else can provide. This is absurd. No practitioner I know, including myself, is unique in his capacity for understanding, affection, loyalty, wit, and all the other qualities present in a good chum. It only seems so to the client.

Moreover, by becoming the buddy of the person to whom you are ministering, you reduce his incentive to develop healthy connections outside of the office and to take the risks necessary to do so. Stealing the initiative of the people you serve harms them.

By now you’re either on board with my concerns, believe I’m unnecessarily worried, or think I’m just plain wrong. What I hope I’ve done, however, is to make it clear that an extra-therapeutic relationship with a mental health professional can’t measure up to an imaginary nirvana. It holds enormous risk for the parties in the consulting room and dares causing permanent damage to each of them, as well as to others. By giving in to a client’s idealized dream of having MORE time and tenderness, the chances are increased of making a nightmare of complexity and disappointment for patient and doctor alike.

I know I have not dealt adequately with the depth of heartache experienced by those who suffer unrequited affection for their therapist; or perhaps I should say “unrequited access” instead. I can do no better than refer you to a wonderful, but exquisitely painful post written by such a person. Indeed, her blog is called Life in a Bind — BPD and Me, the first four words of which serve as a stand-in for both her topic and mine, examined from different perspectives.

You might not like the rules I chose to live by when I practiced, the same rules about which the American Psychological Association gave me no choice. Those ethical guidelines simplified my life and benefited my patients. They permitted me to focus on the most important responsibility my career demanded: helping people. Yes, they limited me and limited those on the other side of the therapeutic moat. We — both of us — needed some boundaries.

Perhaps it is too much to call the doctor’s office a “sacred space.” Yet, the external regulations enforced on patient and therapist are designed to protect each from the other; and, to safeguard each party from the injury he might do to himself if the barriers were lowered. As a therapist, you are therefore unable to assist people in the fulfillment of their dreams about you. As compensation, you have a chance to guide them safely to a healing place. We cannot permit you everything, but in our prohibitions perhaps we can enable you to find everything elsewhere.

In the end, if you don’t like the obstacles erected by all responsible therapists, I invite you to describe a more perfect system. Ideally you will design a new set of ethical principles superior to those psychologists use, less fraught with the problems I’ve described and others just as bad.

Good luck to you. I look forward to reading anything you fashion.

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The first photo is called Joy in Arm Wresting by Bernd Schwabe. The second picture is Two Interlocking Braided Hands by M. Koenitzer. Both are sourced from Wikimedia Commons.

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In addition to psychology, you'll also find me musing on baseball, classical music, love, friendship, how we live, and how best to live. I'll tell a few stories and draw a few conclusions.
I hope that some tales will touch you and others help you to look at yourself and the world anew. Thanks for reading (and thinking) along with me! Your comments are most welcome.

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